Development of electrosurgery goes back to the 1920’s when it was introduced by [1]. Also known as diathermy or electrocautery, electrosurgery went on to revolutionize modern surgery and continues to serve the needs of modern medicine.

Electrosurgery makes use of an electrical current that is generated by a specialized surgical apparatus. Delivered through an active electrode, the current targets the desired tissue, and exits via a neutral electrode. Upon encountering resistance, it generates heat which in turn enables cutting or coagulation. The device may be run in the monopolar mode in which current flows from active electrode to a dispersive pad placed at a distant site on the patient’s body, or alternatively the bipolar mode, where electrodes are positioned in close proximity confining current flow to a small area.

Despite advancements, complications including burns, interference with monitoring devices such as pacemakers, pulse oximeters, and deep brain stimulators continue to pose risks. Electrosurgery can also cause unintended muscle contractions or movement, which may be misinterpreted as inadequate anaesthesia. Also of concern is the presence of flammable gases and alcohol-based skin preparation solutions that may cause unnecessary intraoperative complications.

Case History

A 44-year-old female patient was admitted for a total abdominal hysterectomy under general anaesthesia. The surgical procedure lasted approximately 1 hour and 45 minutes. Intraoperative monitoring included cardiac monitoring, pulse oximetry, non-invasive blood pressure measurement, and blood gas analysis. Monopolar electrosurgery was employed with a reusable dispersive pad placed on the right calf by the operating theatre assistant. No intraoperative alarms or device malfunction warnings were noted. The procedure was successfully completed, and patient was discharged without any immediate postoperative complaints. However, during a follow-up visit one week later, the consultant was informed by the patient that she had developed a second-degree burn at the site of the dispersive pad. The consultant immediately notified the OT manager.

A closer inspection revealed that size and shape of burn resembled contact metals of operating table, leading to the conclusion that improper adhesion of the dispersive pad is most likely to have been the underlying cause of her injury. The patient was managed conservatively with utmost wound care, and an internal review of dispersive pad placement and reassessment protocols was initiated. The burn site healed completely within 3 weeks with no residual scarring or functional impairment. This incident highlighted gaps in practice and presented an opportunity to initiate process improvement.

Discussion

The electrosurgical burn as described above is likely to have been caused by improper placement of dispersive pads which failed to establish adequate contact with the patient’s skin. Modern electrodes are designed and engineered to mitigate risk, yet injuries continue to occur due to inadequate adherence to safety protocols.

Factors that are likely contributors of electrosurgical burns are:

 Loose or inadequately placed dispersive pads: poor contact can lead to heat accumulation and/or in situ sparking.
 Patient movement during surgery: changes in positioning may dislodge pad, increasing resistance and localized heating.
 Alternative current pathways: metal implants or external monitoring devices can create unintended circuits, resulting in burns at unexpected sites.
 Flammable skin preparation solutions: if not allowed sufficient drying time, alcohol-based solutions can ignite especially when exposed to electrosurgical heat sources.

To mitigate risk(s) associated with electrosurgical procedures, the following safety measures should be implemented:

 Proper placement and adhesion of dispersive pads: ensure full skin contact over an adequate surface area (i.e., minimum 70 cm²) and use fresh adhesive grounding pads for better adherence.
 Preoperative skin assessment: remove hair and clean skin to enhance pad-skin contact.
 Reassessment of pad positioning: verify pad placement due to any patient movement.
 Optimal utilization of in-built safety systems: Modern electrosurgical units are equipped with alarms capable of detecting poor pad contact and alert observers.
 Use of bipolar electrosurgery if possible: this eliminates the need for a grounding pad and reduces burn risk.
 Avoidance of alcohol-based skin preparations: ensure complete evaporation before using electrocautery.

Literature Review & Similar Cases

Several cases of electrosurgical burns have been reported in different surgical disciplines. For instance, Mundinger [2] documented a case where a patient with titanium skull implants sustained burns on the forehead due to unintended circuit formation. Similarly, Engel [3] highlighted cases of facial burns caused by electrocautery use in oxygen-rich environments, emphasizing the importance of limiting oxygen supplementation during such procedures.
Electrosurgical burns also carry medicolegal and ethical implications. These injuries are considered preventable medical errors, which may arise from negligence or systemic failures. Reporting such incidents is crucial for improving patient safety and developing better preventive strategies. Palmer, [4-8] have reviewed a series of 19 patients with intra-operative burns requiring plastic surgery and determined that four patients had deep dermal or full thickness burns requiring debridement, skin grafting or musculocutaneous flaps. Their analyses revealed that some of the causes included malfunctioning electrosurgical devices, incorrectly positioned neutral electrodes, presence of moisture under the negative electrode, and blood or fluid creating alternate current pathways. In our case, the cause of burn is likely attributed to improper grounding, or drying, of the conductive jelly during an extended operation, as per our hospital record [9-12].

Diathermy devices may also cause injuries not only to patients, but also to members of operating team. There are three ways in which current can penetrate gloves: hydration (the wet glove becomes conductive), capacitive coupling, and breakdown. Additionally, stray sparks from leaking units or plates pose danger in operating rooms [13]. Leakage of diathermy devices in presence of flammables agents (e.g., oxygen, nitrous oxide, alcohols, etc) has the potential to start fires or even explosions [14].

Conclusion

As long as conventional monopolar electrocautery remains in use the risk of electrosurgical burns must be acknowledged and proactively addressed. Members of surgical team must ensure proper grounding, pad application, reassess pad placement after any patient movement, and adopt modern electrosurgical safety features. Enhanced staff training, implementation of standardized protocols, and incident reporting can significantly reduce the occurrence of such preventable injuries.

References
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